Nokea
A nurse is caring for a patient who has undergone neck resection with a radial forearm free flap. The nurses most recent assessment of the graft reveals that it has a bluish color and that mottling is visible. What is the nurses most appropriate action?
- A. Document the findings as being consistent with a viable graft.
- B. Promptly report these indications of venous congestion.
- C. Closely monitor the patient and reassess in 30 minutes.
- D. Reposition the patient to promote peripheral circulation.
Correct Answer: B
Rationale: A graft that is blue with mottling may indicate venous congestion. This finding constitutes a risk for tissue ischemia and necrosis; prompt referral is necessary.
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A nurse is caring for a patient who has had surgery for oral cancer. When addressing the patients long-term needs, the nurse should prioritize interventions and referrals with what goal?
- A. Enhancement of verbal communication
- B. Enhancement of immune function
- C. Maintenance of adequate social support
- D. Maintenance of fluid balance
Correct Answer: A
Rationale: Verbal communication may be impaired by radical surgery for oral cancer. Addressing this impairment often requires a long-term commitment. Immune function, social support, and fluid balance are all necessary, but communication is a priority issue for patients recovering from this type of surgery.
A patient with cancer of the tongue has had a radical neck dissection. What nursing assessment would be a priority for this patient?
- A. Presence of acute pain and anxiety
- B. Tissue integrity and color of the operative site
- C. Respiratory status and airway clearance
- D. Self-esteem and body image
Correct Answer: C
Rationale: Postoperatively, the patient is assessed for complications such as altered respiratory status, wound infection, and hemorrhage. The other assessments are part of the plan of care for a patient who has had a radical neck dissection, but are not the nurses chief priority.
A patient who had a hemiglossectomy earlier in the day is assessed postoperatively, revealing a patent airway, stable vital signs, and no bleeding or drainage from the operative site. The nurse notes the patient is alert. What is the patients priority need at this time?
- A. Emotional support from visitors and staff
- B. An effective means of communicating with the nurse
- C. Referral to a speech therapist
- D. Dietary teaching focused on consistency of food and frequency of feedings
Correct Answer: B
Rationale: Verbal communication may be impaired by radical surgery for oral cancer. It is therefore vital to assess the patients ability to communicate in writing before surgery. Emotional support and dietary teaching are critical aspects of the plan of care; however, the patients ability to communicate would be essential for both. Referral to a speech therapist will be required as part of the patients rehabilitation; however, it is not a priority at this particular time. Communication with the nurse is crucial for the delivery of safe and effective care.
A staff educator is reviewing the causes of gastroesophageal reflux disease (GERD) with new staff nurses. What area of the GI tract should the educator identify as the cause of reduced pressure associated with GERD?
- A. Pyloric sphincter
- B. Lower esophageal sphincter
- C. Hypopharyngeal sphincter
- D. Upper esophageal sphincter
Correct Answer: B
Rationale: The lower esophageal sphincter, also called the gastroesophageal sphincter or cardiac sphincter, is located at the junction of the esophagus and the stomach. An incompetent lower esophageal sphincter allows reflux (backward flow) of gastric contents. The upper esophageal sphincter and the hypopharyngeal sphincter are synonymous and are not responsible for the manifestations of GERD. The pyloric sphincter exists between the stomach and the duodenum.
A patient with gastroesophageal reflux disease (GERD) has a diagnosis of Barretts esophagus with minor cell changes. Which of the following principles should be integrated into the patients subsequent care?
- A. The patient will require an upper endoscopy every 6 months to detect malignant changes.
- B. Liver enzymes must be checked regularly, as H2 receptor antagonists may cause hepatic damage.
- C. Small amounts of blood are likely to be present in the stools and are not cause for concern.
- D. Antacids may be discontinued when symptoms of heartburn subside.
Correct Answer: A
Rationale: In the patient with Barretts esophagus, the cells lining the lower esophagus have undergone change and are no longer squamous cells. The altered cells are considered precancerous and are a precursor to esophageal cancer. In order to facilitate early detection of malignant cells, an upper endoscopy is recommended every 6 months. H2 receptor antagonists are commonly prescribed for patients with GERD; however, monitoring of liver enzymes is not routine. Stools that contain evidence of frank bleeding or that are tarry are not expected and should be reported immediately. When antacids are prescribed for patients with GERD, they should be taken as ordered whether or not the patient is symptomatic.